Cardiology Flashcards
Angina pectoris 3 features
Constricting chest pain
Brought on by exercise
Relieved within 5 min by rest or GTN
Angina symptoms
Constricting chest pain, sweatiness, nausea, dyspnoea, faintness
Investigations for angina
ECG - normal, or ST depression, T wave inversion, signs of past MI
Bloods - FBC, U+E, TFT, lipids, HbA1c, cardiac enzymes to rule out MI
In patient’s whom stable angina cannot be excluded, first line test is CT coronary angiography
Consider echo and CXR
Exercise ECG, stress echo
Stable angina management
Secondary prevention - stop smoking, dietary advice, hypertension control, diabetes control, 75mg aspirin, statins, consider ACEi
Symptom relief - GTN spray
Anti-angina - beta blocker and/or CCB Consider revascularisation (PCI, CABG)
Risk factors for acute coronary syndrome
Non-modifiable: Age, sex, family history
Modifiable: Smoking, obesity, HTN, DM, hyperlipidaemia, sedentary lifestyle
ACS investigations
Troponin/cardiac enzymes (normal in UA, raised in NSTEMI/STEMI) ECG Other bloods - FBC, U+E, glucose, lipids Echo CXR
ECG in ACS
STEMI - ST elevation, hyperacute T waves, new LBBB (T waver inversion and pathological Q waves come hours/days later)
UA/NSTEMI - Normal, T wave inversion, ST depression, non-specific changes
Acute management of STEMI
Morphine, metoclopramide, oxygen, GTN, aspirin 300mg
Consider adding clopidogrel
Fondaparinux
Beta blocker
If <12hr from symptoms and <120 min from first medical contact -> PCI
If >120 min -> fibrinolysis
Acute management of NSTEMI
Morphine, metoclopramide, nitrates, aspirin (300mg), oxygen
Calculate GRACE score
Low risk -> secondary prevention, discharge, follow up
High risk -> fondaparinux, add clopidogrel, beta blocker, IV nitrate is pain continues, +/- abciximab, cardiology review for angiography
Secondary prevention following ACS
Stop smoking Control DM and HTN Statins Diet and exercise 75mg aspirin OD and ticagrelor for at least 12m Fondaparinux until discharge Beta blocker ACE inhibitor
Driving after MI
1 week after successful angioplasty, 4 weeks after ACS without angioplasty
Working after MI
Depends on the patient and the nature of their work. Can not continue being an airline pilot or air traffic controller.
May need to wait if job involves driving
Complications of MI
Cardiac arrest, cardiogenic shock, heart failure, arrhythmias, pericarditis, embolism, cardiac tamponage, mitral regurg, VSD, dresslers syndrome
Causes of arrhythmias
IHD, structural changes, cardiomyopathy, pericarditis
Caffeine, smoking, alcohol, pneumonia, drugs, metabolic imbalance, pheochromocytoma
Investigations for arrhythmias
FBC, U+E, glucose, calcium, magnesium, TSH ECG 24h ECG or continuous ECG monitoring Echo Exercise ECG/cardiac catheterisation
Types of regular narrow complex tachycardias
Sinus tachycardia (infection, pain, anxiety, exercise, alcohol, caffeine, etc) Atrial flutter (atrial activity 300bpm with regular ventricular activity -> sawtooth appearance) Atrioventricular re-entry tachycardia (eg. WPW, accessory path from atria to ventricles) Atrioventricular nodal re-entry tachycardia (circuit formed around the AVN, very common)
Types of irregular narrow complex tachycardias
AF
Atrial flutter with a variable block (atrial rhythm is regular but ventricular rhythm is irregular)
Management of supraventricular (narrow complex) tachycardias
If there are adverse signs (shock, syncope, MI, HF) -> synchronised DC cardioversion, and/or amiodarone (300mg over 20min then 900mg over 24h)
No adverse signs ->
irregular -> treat as AF (beta blocker/CCB/digoxin, consider amiodarone or cardioversion, give anticoag)
No adverse signs ->
regular -> vagal manoeuvres, adenosine (6,12,12) -> if sinus not achieved seek expert help, if sinus achieved then monitor
Types of broad complex tachycardia
VF
VT
Torsades de pointes (polymorphic VT)
Any cause of narrow-complex tachycardia when in combination with a BBB
Management of broad complex tachycardia
Adverse signs -> synchronised DC cardioversion, +/- amiodarone
No adverse signs -> correct electrolyte problems
If regular give amiodarone
If irregular seek expert help
If no success give syncronised DC cardioversion
AF causes
HF, HTN, IHD, PE, mitral valve disease, pneumonia, hyperthyroidism, caffeine, alcohol, post-op, hypokalaemia, hypomagnesaemia
Investigations for AF
ECG (irregularly irregular, absent P waves)
U+E, TFT, cardiac enzymes
Echo (look for left atrial enlargement, mitral valve disease, poor LV function, structural abnormalities)
Managing acute AF
Adverse signs -> synchronised DC cardioversion +/- amiodarone
No adverse signs and AF started <48hrs ago -> rate control (BB, CCB, digoxin) or rhythm control (cardioversion, flecainide, or amiodarone)
No adverse signs and started >48hrs ago -> rate control. If rhythm control indicated then pt must be anticoagulated for >3weeks
Contraindication for flecainide
Structural heart disease, IHD
Managing chronic AF
Rate control or rhythm control
Rhythm control indications: symptomatic or HF, younger, AF due to a corrected precipitant. Rhythm control can be DC cardioversion or flecainide (if IHD/structural heart disease use amiodarone)
Rate control includes beta blocker (bisoprolol), or CCB (diltiazem). Add in digoxin if unsuccessful. Use digoxin monotherapy if other two are contraindicated or if HF.
Anticoagulation and AF
CHA2DS2Vasc 0 - no anticoag 1 (male) - offer anticoag 1 (female) - no anticoag 2 - give anticoag
Give DOAC or warfarin (INR 2-3)
HASBLED gives you a score for risk of bleeding whilst on anticoag
Wolf Parkinson White
- what is it
- what does ECG show
Congenital accessory pathway between atria and ventricles
Resting ECG shows short PR interval, wide QRS complex (slurred upstroke or delta wave), and ST-T changes
Management may include ablation of the pathway
Causes of sinus bradycardia
Physical fitness, vasovagal attack, drugs (BB, digoxin, amiodarone), hypothyroidism, hypothermia, raised ICP, cholestasis
Types of heart block
1st degree: long PR interval
2nd degree Mobitz 1: progressive lengthening of PR then a dropped QRS then pattern resets (Wenckebach phenomenon)
2nd degree Mobitz 2: QRS regularly missed (2:1 or 3:1, etc). May progress to complete heart block.
3rd degree/complete heart block: no relationship between P wave and QRS. Haemodynamic compromise. Emergency. PPM required.
Causes of complete heart block
IHD, idiopathic, congenital, aortic valve calcification, cardiac surgery, trauma, digoxin toxicity
Hypercalcaemia on ECG
short QT
Hypocalcaemia on ECG
long QT, small T waves
Hypokalaemia on ECG
Small T waves, prominent U waves, peaked P waves
Hyperkalaemia on ECG
Tall tented T waves, small/absent P waves, broad QRS, sine wave, asystole
Pericarditis on ECG
ST elevation (saddle shaped) in all leads
ECG territories for MI
ECG leads, heart territory, coronary artery
1, aVL, V4, V5, V6 = lateral (circumflex)
V1, V2, V3 = anterioseptal (LAD)
2, 3, aVF = inferior (right coronary artery)
Posterior MI ECG changes
Reciprocal changes (upside down changes) are seen. These are changes that appear when looking at ischaemic myocardium from the other side of the heart. Eg. A posterolateral MI would show ‘upside down’ ST elevation in V1-V3.
LBBB on ECG
QRS>0.12, W in V1 (due to notching of S wave), M pattern in V6, dominant S in V1, inverted T waves in 1, aVL, V5 and V6
LBBB causes
IHD, HTN, cardiomyopathy, idiopathic fibrosis
New LBBB may represent a STEMI
RBBB on ECG
QRS>0.12, RSR pattern in V1 (M shape), diminant R wave in V1, inverted T waves in V1, V2, V3. Wide slurred S wave in V6 (W)
Causes of RBBB
Normal variant, pulmonary embolism, cor pulmonale
Right axis deviation ECG
QRS complexes in 1 and 3 +/- 2 are pointing towards each other
Causes of right axis deviation
RVH, PE, anterolateral MI, WPW, left posterior hemiblock
Left axis deviation on ECG
QRS complexes in 1 and 3 point away from eachother
Causes of left axis deviation
left anterior hemiblock, inferior MI, VT, WPW, LVH
Systolic vs. diastolic heart failure (how they are different, ejection fractions, causes)
Systolic failure - inability of ventricles to contract normally (reduced CO), ejection fraction <40%, causes include IHD, MI, cardiomyopathy
Diastolic failure - inability of ventricles to relax and fill properly, causing icnreased filling pressures, EF >50%, causes include ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity
Systolic and diastolic failure may coexist
Left ventricular failure vs right ventricular failure
LVF: dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough, pink frothy sputum, wheeze, nocturia, cold peripheries, weight loss, pulm oedema
RVF: peripheral oedema, ascites, nausea, anorexia, facial engorgement, epistaxis
Causes: LVF, pulm stenosis, lung disease (cor pulmonale)
Signs of heart failure
cyanosis, hypotension, narrow pulse pressure, pulsus alternans, displaced apex (LV dilatation), RV heave (pulm hypertension), signs of valve disease
Peripheral oedema, wheeze, facial engorgement, pink frothy sputum, etc, depending on type of HF
Investigations
ECG and BNP - if both are normal than alternative diagnosis should be considered. If either is abnormal then echo is required.
BNP raised - ECHO in 6 weeks
BNP significantly raised - ECHO in 2 weeks
Bloods: FBC, U+E, BNP
CXR
ECG (may indicate cause)
Echo (key investigation - may indicate the cause and assess LV function)
Severity staging for HF
New York Classification of HF
1 = heart disease present but no undue dyspnoea from ordinary activity
2 = comfortable at rest, dyspnoea during ordinary activities
3 = less than ordinary activity causes dyspnoea, which is limiting
4 = dyspnoea present at rest, all activity causes discomfort
LVF findings on CXR
ABCDE
Alveolar oedema (perihilar bat wing shadowing)
Kerley B lines (sepral lines, due to oedema)
Cardiomegaly
Dilated prominent upper lobe veins
Pleural effusions
Acute heart failure management
Emergency
Sit patient upright
High flow oxygen
Ix whilst giving treatment (CXR, ECG, U+E, troponin, ABG, ?echo, ?BNP)
Slow IV diamorphine
Furosemide 40-80mg IV slowly
GTN spray. If BP >100 start nitrate infusion (isosorbide dinitrate)
Consider CPAP if patient is worsening
Once stable: daily weight, oral furosemide, ACE-i if EF<40%, consider BB/spironolactone, consider pacing
Signs and symptoms of acute heart failure
Symptoms: dyspnoea, orthopnoea, pink frothy sputum, any recent drugs?
Signs: distressed, pale, sweaty, tachycardia, tachypnoea, pulsus alternans, raised JVP, fine lung crackles, gallop rhythm, wheeze
Bradycardia management
Adverse signs -> atropine 500mcg IV ->
- If unsuccessful repeat atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help
- If successful and risk of asystole -> atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help
- If successful and no risk of asystole -> observe
No adverse signs -> risk of asystole -> atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help
No adverse signs -> no risk of asystole -> observe
Chronic heart failure management
Stop smoking, stop alcohol, less salt, optimise weight and nutrition
Treat cause
Treat exacerbating factors
Annual flu vaccine and one off pneumococcal vaccine
Drugs:
First line: ACE-i (ramipril) and a beta blocker (bisoprolol)
Second line: aldosterone antagonist (spironolactone) or hydralazine in combination with a nitrate
If symptoms persist -> cardiac resynchronisation therapy or digoxin, or ivabradine
Symptom relief: furosemide
HTN definitions (clinic and 24hr ambulatory)
Clinic readings persistently >= 140/90
24h ambulatory pressure average >= 135/85
HTN classification
Primary (most common): no single disease causing the rise in BP
Secondary:
renal disease - glomerulonephritis, chronic pyelonephritis, adult polycystic kidney disease, renal artery stenosis
endocrine -
primary hyperaldosteronism, phaeochromocytoma, cushings, liddles, congenital adrenal hyperplasia, acromegaly
others -
glucocorticoids, NSAIDs, pregnancy, coarctation of the aorta, COCP
HTN investigations
24hr BP monitor
Fundoscopy (hypertensive retinopathy)
Urine dipstick (renal disease)
ECG (LVH, IHD)
U+E - renal disease (cause or consequence)
HbA1c
Lipids
HTN Mx
Low salt, low caffeine, stop smoking, stop alcohol, fruit and veg, exercise, lose weight
ABPM>=135/85 (stage 1 HTN): treat if <80 and end organ damage/CVD/CKD/DM, consider drugs and lifestyle to adults <60 with stage 1 HTN
ABPM >=150/95 (stage 2 HTN) offer drug Mx regardless of age
<55 or T2DM -> A -> A+C or A+D -> A+C+D
> 55 and no T2DM or afro-caribbean and no T2DM -> C -> A+C or A+D -> A+C+D
Blood pressure classification (stage 1, stage 2, severe)
Stage 1: clinic BP >=140/90 and ABPM average >=135/85
Stage 2: clinic BP >=160/100 and ABPM >=150/95
Sever: clinic systolic >=180 or clinic diastolic >=110
BP targets with treatment
<80 - clinic 140/90, ABPM 135/85
> 80 - clinic 150/95, ABPM 145/85
What is rheumatic fever
Systemic infection. More common in developing countries. Recurs unless prevented.
Pharyngeal infection with group A beta-haemolytic streptoccoci triggers rheumatic fever 2-4 weeks later.
Diagnostic criteria for rheumatic fever
Jones criteria. Must be evidence of recent strep infection plus 2 major criteria or 1 major and 2 minor.
Major criteria: carditis/endocarditis, arthritis, subcut nodules, erythema marginatum, sydenhams chorea
Minor criteria: fever, raised ESR/CRP, arthralgia, prolonged PR interval, previour rheumatic fever
Management of Rheumatic fever
Bed rest until CRP normal for 2wks Benzylpenicillin IV stat then phenoxymethylpenicillin PO QDS for 10 days Analgesia (aspirin or NSAIDs) Immobilise joints in severe arthritis Haloperidol/diazepam for chorea
Causes of mitral regurgitation
LV dilatation, annular calcification (elderly), rheumatic fever, infective endocarditis, mitral valve prolapse, connective tissue disorders, cardiomyopathy, congenital
Symptoms and signs of mitral regurgitation
Symptoms: SOB, fatigue, palpitations, plus symptoms of underlying cause
Signs: AF, displaced hyperdynamic apex, pansystolic murmur at apex radiating to axilla, soft S1 split S2, loud P2. the more severe the larger the left ventricle
MR Mx
control rate if fast AF
Anticoag if: AF, hx of VTE, prosthetic valve, additional mitral stenosis
Diuretics improve symptoms
Valve replacement or repair
Mitral valve prolapse causes
Most common valvular abnormality
Occurs alone or with: ASD, turners, PDA, cardiomyopathy, marfans, osteogenesis imperfecta, WPW
Signs of mitral valve prolapse
Mid systolic click and/or a late systolic murmur
Mitral valve prolapse management and complications
Management: beta blocker and/or surgery
Complications: MR, cerebral emboli, arrhythmia, sudden death
Mitral stenosis causes
rheumatic fever, congenital, prosthetic valve
Signs and symptoms of mitral stenosis
Symptoms of pulm hypertension: dyspnoea, haemoptysis, chronic bronchitis
Hoarseness, dysphagia, bronchial obstruction, fatigue, palpitations, chest pain, emboli, infective endocarditis
Signs: malar flush on cheeks, low vol pulse, AF, RV heave
Loud S1, opening snap, rumbling mid-diastolic murmur
Mx of mitral stenosis
rate control and anticoag if in AF
Diuretics reduce preload and pulm venous congestion
Balloon valvuloplasty if non-calcified
Open mitral valvotomy or valve replacement
Aortic stenosis causes
senile calcification, congenital, rheumatic fever
Signs and symptoms of aortic stenosis
syncope, angina, heart failure (exertional dyspnoea), dizziness, emboli
Slow rising pulse with narrow pulse pressure, heaving apex beat, LV heave, aortic thrill
Ejection systolic murmur heard at the left sternal edge, base and aortic area, radiating to carotids
Management of aortic stenosis
Valve replacement
Percutaneous valvuloplasty for pt not fit for surgery
Aortic regurgitation causes
Acute: infective endocarditis, ascending aortic dissection, chest trauma
Chronic: congenital, connective tissue disorders, rheumatic fever, RA, HTN, osteogenesis imperfecta
Signs and symptoms of aortic regurgitation
Exertional dyspnoea, orthopnoea, PND, palpitations, angina, syncope, HF
Collapsing water hammer pulse, wide pulse pressure, displaced apex beat, high pitched early diastolic murmur (heard best in expiration with patient sat forward), head nodding with each heart peat, carotid pulsation, capillary pulsation in nail bed, pistol shot sound over femoral arteries
Management of aortic regurgitation
Reduce systolic hypertension (ACE-i)
Echo regularly
Treat underlying cause
Valve replacement
Infective endocarditis risk factors
previous episode of IE Renal failure, DM, immunosuppression, skin breaches Previously normally valve (mitral valve most common) Rheumatic valve disease Prosthetic valve Congenital heart defects IVDU Recent piercing
Causative organisms of IE
Staph aureus most common cause
Strep viridans most common in developing countries
Staph epidermidis common in post-op (indwelling lines)
Signs and symptoms of IE
Fever + new murmur = IE until proven otherwise
Septic signs, new murmur (due to vegetations), heart block, vasculitis, microscoping haematuria, AKI, retinal haemorrhages, splinter haemorrhages, osler nodes, janeway lesions, emboli
Diagnostic criteria for IE
Modified Duke Criteria (2 major, or 1 major and 3 minor, or all 5 minor)
Major: positive blood culture, encocardium involved
Minor: predisposition, fever >38, vascular phenomena, immunological phenomena, positive blood culture that does not meet major criteria
Investigations for IE
Blood cultures (three sets at different times)
Bloods: FBC, ESR/CRP, U+E, Mg, LFT, RhF +ve
Urinalysis for microscoping haematuria
CXR (cardiomegaly, pulm oedema)
ECGs (heart block)
Echo (vegetations only if >2mm, mitral valve lesions, aortic root abscess)
CT to look for emboli
Management of infective endocarditis
Initial blind therapy: amoxicillin or gentamicin/vancomycin
Staph IE: flucloxacillin (add rifampicin and gentamicin if prosthetic valve)
Strep IE: benzylpenicillin
Surgery: severe valve incompetence, aortic abscess, abx resistant, cardiac failure, recurrent emboli
Dilated cardiomyopathy
- what is it
- associations
Dilated flabby heart of unknown cause
Associated with alcohol, HTN, chemo, haemochromatosis, viruses, autoimmune, peri/post partum, thyrotoxicosis, congenital
Hypertrophic cardiomyopathy (HOCM)
LV outflow tract obstruction from asymmetrical septal hypertrophy
Leading cause of sudden cardiac death in the young
Autosomal dominant, or sporadic
Mx: beta blockers, verapamil, amiodarone, anticoag, septal myomectomy
Acute pericarditis causes
Idiopathic Virus (coxsachie) Bacteria (TB, pneumonia, rheumatic fever) Autoimmune Drugs Metabolic (uraemia, hypothyrdoidism) trauma/surgery Malignancy/Radiotherapy MI/Chronic heart failure
Clinical features of pericarditis
Central chest pain worse on inspiration or lying flat, relief by sitting forward
Pericardial friction rub may be heard
Pericardial effusion and cardiac tamponade may be seen
Fever may occur
Ix for pericarditis
ECG (saddle shaped concave ST elevation in all leads, and PR depression) Bloods: FBC, U+E, ESR, cardiac enzymes CXR (cardiomegaly) Transthoracic echo CMR or CT
Mx of pericarditis
NSAIDS or aspirin with gastric protection for 1-2 weeks
Add colchicine for 3 months to reduce recurrence
Bed rest
Treat cause
If autoimmune consider steroids
Pericardial effusion causes
Pericarditis, myocardial rupture, aortic dissection, pericardium filling with pus, malignancy
Clinical features of pericardial effusion
Dyspnoea, chest pain, nausea, bronchial breathing, muffled heart sounds, cardiac tamponade?
Diagnosis and management of pericardial effusion
CXR (enlarged, globular heart)
ECG (low voltage QRS complexes)
Echo (echo-free zone surrounding the heart)
Management: pericardiocentesis may be diagnostic or therapeutic
Constrictive pericarditis
- what is it
- clinical features
- tests
- management
rigid pericardium
Presents with RVF -> raised JVP, kussmaul sign (raised JVP with inspiration), soft diffuse apex beat, quiet heart sounds, S3, hepatosplenomagely, ascites, oedema
Tests: CXR (small heart), CT/MRI, echo, cardiac catheterisation
Mx: surgical excision, medical treatment to address cause and symptoms
what is a cardiac tamponade
Pericardial effusion that raises intrapericardial pressure reducing ventricular filling and thus dropping cardiac output
Clinical features of cardiac tamponade
tachycardia, hypotension, pulsus paradoxus, raised JVP, kussmaul sign, muffled S1 and S2
Diagnosis of cardiac tamponade
Becks triad (hypotension, raised JVP, muffled heart sounds)
ECG: low voltage QRS complexes
Echo is diagnostic (echo-free zone)
Management of cardiac tamponade
Urgent pericardiocentesis (send fluid for cytology, staining and cultures)
DVLA rules for
- angina
- MI
- Dysrrhythmias
- pacemaker implant
- syncope
- HTN
- angina: stop if symptoms occur at rest or with emotion. Can continue when under control.
- MI: stop for 4 weeks if CABG, stop for 1wk if angioplasty
- Dysrrhythmias: stop for 4wks after successful control
- pacemaker implant: stop for 1 wk
- syncope: no restriction if simple faint, stop for 4wks if cause identified and treated, stop for 6 months if cause not identified/treated
- HTN: can continue unless treatment causes unacceptable side effects
